Use of Decision Support Tools To Empower Pregnant Women: Systematic Review

JOURNAL OF MEDICAL INTERNET RESEARCH Ngo et al
Review
Use of Decision Support Tools to Empower Pregnant Women:

Systematic Review
Elin Ngo1, MSc; Maria Bich-Thuy Truong1, MSc; Hedvig Nordeng1,2, MSc, PhD
1
PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway
2
Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
Corresponding Author:
Elin Ngo, MSc
PharmacoEpidemiology and Drug Safety Research Group
Department of Pharmacy
University of Oslo
Postboks 1068 Blindern
Oslo, 0316
Norway
Phone: 47 93849866
Email: e.t.p.ngo@farmasi.uio.no
Abstract
Background: Women face many health-related decisions during pregnancy. Digitalization, new technology, and a greater focus
on empowering patients have driven the development of patient-centered decision support tools.
Objective: This systematic review provides an overview of studies investigating the effect of patient-centered decision support
tools for pregnant women.
Methods: We searched 5 online databases, MEDLINE, EMBASE, Web of Science, PsycINFO, and Scopus, from inception to
December 1, 2019. Two independent researchers screened titles, abstracts, and full-texts against the inclusion criteria. All studies
investigating the effect of patient-centered decision support tools for health-related issues among pregnant women were included.
Study characteristics and results were extracted using the review management tool Rayyan and analyzed according to topic, type
of decision support tools, control group, outcome measurements, and results.
Results: The 25 eligible studies covered a range of health topics, including prenatal screening (n=10), gestational diabetes and
weight gain (n=7), lifestyle (n=3), blood pressure and preeclampsia (n=2), depression (n=1), asthma (n=1), and psychological
well-being (n=1). In general, the use of decision support tools increased women's knowledge, and recording symptoms enhanced
satisfaction with maternity care.
Conclusions: The opportunities created by digitalization and technology should be used to develop innovative patient-centered
decision support tools tailored to support pregnant women. Effect on clinical outcomes should be documented.
(J Med Internet Res 2020;22(9):e19436) doi: 10.2196/19436
KEYWORDS
decision support tools; pregnancy; mobile application; empowerment
that are best for themselves and improve communication with

Introduction their care providers [1,2].
Background Patient involvement in decision making varies among patient
Patient-centered decision support tools are developed to involve groups but is especially common among young women [3],
patients in their own health-related decisions by (1) clearly coinciding with the time in life at which they become pregnant
stating the decisions that need to be made, (2) providing and, for many women, face completely new health-related
information about the options, outcomes, risks, and benefits, decisions. In particular, decisions about medication use in
and (3) clarifying personal values. Decision support tools aim pregnancy may be challenging, as it requires handling the unique
to complement, not replace, counseling from health care task of weighing the benefits and risks of treatment for
providers. The goal is to empower patients to make the decisions themselves against the benefits and risks for their unborn child.
http://www.jmir.org/2020/9/e19436/ J Med Internet Res 2020 | vol. 22 | iss. 9 | e19436 | p. 1
(page number not for citation purposes)
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These situations are not uncommon, as over 60% of pregnant Type of Participants
women use medications at least once during pregnancy [4-6]. All studies focusing on women who used one or several
Prior studies [7] have shown that pregnant women actively seek patient-centered decision support tools during pregnancy
information to enable them to make decisions about medication regarding health- or pregnancy-related issues were included in
use in pregnancy. First time pregnant women are more likely this review. Studies evaluating decision support tools for use
to seek information about medications and health-related in the prepregnancy period, postpartum period, or
problems during pregnancy than women who have previously delivery-related (eg, support during birth, cesarean delivery,
had children [8-10]. Despite the frequent use of the internet, mode of birth after cesarean section, or breech position) were
pregnant women tend not to discuss the information they have excluded.
retrieved online with their health care providers [11]. Provision
Type of Intervention
of tailored and credible information though a decision support
tool may have the potential to empower and improve informed All types of tools (digital or paper-based) developed to support
decision making among pregnant women [12]. women’s health-related decisions by providing tailored
information to her situation or recordings in pregnancy were
The last literature review [13] on patient-centered tools to included.
support women’s decisions during pregnancy was published in
2012. Since then, there has been an increased focus on Type of Control Group
digitalization and novel tools to empower patients. An updated Participants in the control group were pregnant women who
literature review could help identify knowledge gaps concerning received standard prenatal care or used a different decision
patient-centered decision support tools for pregnant women support tool than the participants in the intervention group. A
[14,15]. control group was not required in descriptive studies.
Objective Types of Outcome Measures
The aim of this systematic review was to identify studies Outcome measures that assessed the women’s knowledge,
evaluating the efficacy of patient-centered decision support satisfaction, decision making, quality of life, use experience,
tools for pregnant women and provide guidance for future behaviors, or control of clinical measures in pregnancy were
research and the development of new, efficient tools. included.
Methods Study Selection and Data Extraction

All studies identified from the 5 databases were saved in
Literature Search Strategy reference management software (EndNote X8.1). Duplicates
The following online databases were searched from inception were removed, and the remaining studies were uploaded to free
to January 18, 2019: MEDLINE, EMBASE, Web of Science, online systematic review data management software (Rayyan)
PsycINFO, and Scopus. An updated search was conducted [17]. First, the 2 researchers (EN and MT) independently
December 1, 2019. Each database was searched using a screened titles and abstracts against the inclusion criteria, and
customized search strategy (Multimedia Appendix 1). The disagreements were discussed until consensus was reached. The
following keywords or MeSH terms (Medical Subject Headings) full-texts included from the previous round were then
were used for the database search: pregnancy, parturition, independently screened and categorized by the same researchers
prenatal care, antenatal care, mobile application, mobile health, using EndNote and Excel (Microsoft Inc). At this step, excluded
decision support techniques, choice behavior, patient education, studies were categorized as (1) full-text not available, (2) foreign
decision making, satisfaction, quality of life, and knowledge. language, (3) wrong publication type, (4) wrong study design,
(5) the study did not investigate the use of a decision support
Selection of Studies tool, or (6) the study did not include pregnant women or
The studies were selected in accordance with PRISMA irrelevant outcome (eg, delivery, cesarean section, and economic
(Preferred Reporting Items for Systematic Reviews and analyses).
Meta-analyses) guidelines [16]. The studies included after the full-text screening were analyzed
Type of Study using a data extraction form (Multimedia Appendix 2).
Information extracted from the studies included information
Randomized controlled trials, cohort studies, register-based
about the study design, population, setting, method of
studies, and case-control studies were eligible for inclusion.
recruitment, type of intervention or decision support tool, control
Reviews, nonoriginal studies, Delphi studies, editorials,
group, outcomes measure, and results. Findings were grouped
commentaries, letters to the editor, animal studies, and
into major topics such as prenatal screening, gestational diabetes
conference papers or abstracts were excluded. Full-texts in
and weight gain, lifestyle, blood pressure and preeclampsia,
English were included in this review. Moreover, full texts in
depression, asthma, and physiological well-being.
Norwegian, Swedish, or Danish were included, as the authors
could fluently read papers in these languages.

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search (January 18, 2019) from the 5 online databases, with

Results 7411 remaining after the deletion of duplicates. Of these, 7074
Search Findings studies were excluded based on titles and abstracts, and 337
full-texts were screened for eligibility (Figure 1). The most
A total of 10,726 studies were initially identified in the first common reason for exclusion was wrong study design (n=126).
Figure 1. Flowchart of the identification and selection of evaluated studies.
The updated search (December 1, 2019) identified 1221 new Included Studies
studies from the same databases as the first search. Of these, A total of 25 studies were included in this review, all in English.
only 1 study was eligible for inclusion in this review after the The studies covered 7 major topics: prenatal screening,
screening process. gestational diabetes and weight gain, blood pressure and
preeclampsia, lifestyle, depression, asthma, and physiological
well-being (Multimedia Appendix 3). The decision support

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tools were provided either as digital tools (webpage, mobile paper-based decision support tool investigated the effect on
app, video, SMS text messages, n=24) or as written educational knowledge (n=1), attitudes (n=1), decision making (n=1), and
material (n=1). Outcome measures included in the digital clinical measures (n=2) (Figure 2). Several studies used multiple
decision support tools were clinical measures (n=10), knowledge instruments for measuring the same outcome. The total number
level (n=10), decision making (n=10), satisfaction or attitudes of outcome measures may thus exceed the number of studies
(n=8), use experience (n=6), and lifestyle (n=3). One included.
Figure 2. Effect of digital decision support tools.
Pregnant women at ≤26 gestational weeks were included in

Effect of Patient-Centered Decision Support as these studies. One study [24] did not have a cut-off on
Interventions gestational weeks. Nine decision support tools were digital and
Prenatal Screening one was provided as written material. The outcomes measured
in these studies were knowledge (n=9), decision making (n=11),
Ten studies [18-27] evaluated the effect of a patient-centered
satisfaction or attitudes (n=6), clinical measures (n=3), and use
decision support tool on women’s decisions about performing
experience (n=1).
prenatal screening for genetic disorders and birth defects.

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Overall, women who used a decision support tool had higher standard care. They did, however, refrain from alcohol to a
knowledge scores than the control group and knew about the larger extent after 6 months (computer-tailored letter: 78%;
risks and benefits of genetic screening in pregnancy (Multimedia standard care: 55%, P=.04) [36]. Providing SMS text messages
Appendix 3). Independent of the type of decision support tool, with general pregnancy information also resulted in a decreased
the results show decreased decisional conflict for women in the alcohol consumption in pregnancy compared to maternity care
intervention group compared to those in standard care. This alone (SMS text messages: 3.5%; standard maternity care: 1.1%;
indicated that women using decision support tools felt more P<.098) [37].
informed and were more aware of the risk and expected outcome
of each option when compared to their counterparts
Blood Pressure and Preeclampsia
[19-21,23,27]. Women using decision support tools also had Two studies [38,39] investigated the effect of an app on blood
better knowledge scores [19,21-23,25-27], except for in 2 studies pressure readings and knowledge about preeclampsia. Women
[20,24] which showed no effect on knowledge. Both digital and using the app recorded their blood pressure and shared the
paper-based decision support tools showed no difference in information with their care provider more frequently [38]. They
attitudes and frequency of completing screening (digital: 32%; also had significantly higher knowledge scores than women not
paper-based: 15%; P=.087) [19,23,25,27]. using the app (app user: 78.1; control: 15.8; P<.001) [39].
Gestational Diabetes and Weight Gain Depression

Seven studies [28-33] investigated the effect of using decision A recently published study [40] investigated the effect of a
support tools on blood glucose level control for pregnant women mood tracking and alert app among pregnant women with
with gestational diabetes. Two studies [28,34] evaluated the depression on mood and depressive symptoms measured by the
effect on gestational weight gain in general and among women Patient Health Questionnaire 9 [41]. The app also provided
with gestational diabetes. The evaluated decision support tools information about mental health and physical activity and alerted
were apps (n=4), web-based tools (n=2), and SMS text prenatal providers when depressive symptoms were worsening.
message–based (n=1). Outcome measures were knowledge level All women in the study also had access to a patient portal that
(n=1), satisfaction (n=2), use experience (n=2), blood glucose provided an overview of upcoming appointments and clinical
level control (n=3), and weight control (n=2). results and which could be used to request prescription refills.
Women in the intervention group recorded depressive symptoms
Women using an app to record blood glucose level readings an average 5.3 days per week. Their health care providers were
daily, in addition to receiving SMS text messages from their more likely to mention mental health at check-ups (P=.02), and
doctor with advice when readings were abnormal, reported more women using the app had a higher rate of referral to a mental
blood glucose level readings than women who recorded their health specialist (P=.03) [40].
blood glucose level readings in a paper diary (app: 3.8; paper
diary: 2.6 recordings per day) [30]. The vast majority of women Asthma
with diabetes using the apps felt more satisfied with the care One study [42] investigated the effect of an app on asthma
they received [29]. Women receiving tailored advice online symptoms during pregnancy. In that study, 58% of the women
(about blood glucose) from their care provider also had a better had moderate to severe asthma. Women in the intervention
understanding of the risks related to gestational weight gain for group received a chronic obstructive pulmonary disease
themselves (tailored advice: 34%; control: 21%; P=.044) and measurement device (COPD‐6) in addition to an app for
the fetus (tailored advice: 62%; control: 38%; P=.001) [31]. recording symptoms and medication use weekly, as well as with
Women using apps as decision support tool showed no weekly feedback. Women in the intervention groups had better
difference or improvements in in blood glucose level control control of symptoms (Asthma Control Questionnaire: –0.30 vs.
[28,30]. However, women who used a web-chat with direct 0.06, P=.02), and quality of life (Asthma Quality-of-life
contact and feedback from their health care providers had Questionnaire score: 0.51 vs. –0.22, P=.002) after 6 months
significant lower fasting blood glucose level (web-chat and [42].
feedback: 4.3; control: 5.3; P<.001) and 2-hour postprandial Psychological Well-Being
blood glucose (web-chat and feedback: 5.8; control: 6.9;
One study [43] investigated the use of a decision support tool
P<.001) [33]. They also felt they had more control of their
and its effect on psychological well-being. Women received
symptoms and a better overview of their blood glucose when
SMS text messages with information tailored to their gestational
using a decision support tool as a supplement to standard care
week, 2 times per week from gestational week 28 onward.
[32].
Women receiving these SMS text messages had lower anxiety
Lifestyle scores (2.8 vs. 4.9, P=.002) and higher confidence scores (8.9
Three studies [35-37] investigated the effect of decision support vs. 7.8, P=.001) than women receiving standard care only [43].
tools on alcohol consumption and smoking cessation during
pregnancy. The tools were an app [35], a web-based tool [36], Discussion
and an SMS text message–based tool [37].
Main Findings
A computer-tailored letter providing information about the risk This systematic review provides an updated overview of current
of alcohol use in pregnancy had no effect on women’s knowledge regarding patient-centered decision support tools
refrainment from alcohol use after 3 months when compared to

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for women during pregnancy. The 25 studies included more still lacking. Moreover, there is clear potential for developing
than 5000 women covering a broad range of health conditions decision support tools to support decisions about medications
in pregnancy. The majority of studies investigated the effect of in pregnancy. Nausea and vomiting in pregnancy, pain and
a decision support tool in relation to prenatal screening (10/25, self-managed conditions such as heartburn and constipation are
40%) or gestational diabetes and weight gain during pregnancy examples where digital treatment algorithms may yet prove to
(7/25, 28%). In general, the decision support tools were found be useful.
to increase the women’s knowledge and enhance communication
Our findings expand on and support earlier reviews that reported
with health care providers. Digital decision support tools also
the potential benefits of decision support tools for decisions
seemed to be more convenient and led to more recorded clinical
related to pregnancy. Both Say et al [49] and Dugas et al [13]
data than what was recorded by paper-based tools.
advocated the potential for decision support tools to improve
Interestingly, almost all decision support tools, both digital and obstetric care. Our review included more studies that were recent
written material, increased the women’s knowledge compared (since 2012), even though our inclusion criteria were focused
to knowledge received through standard care [19,21-27,31]. on decision support tools used only by women during pregnancy.
However, the majority of women participating in the studies More decision support tools after 2012 are electronic, as apps
were highly educated, and had been pregnant before; thus, they and web-based. The opportunities created by digitalization and
may not be representative of the general pregnant population. technology should be used to develop innovative
In addition, knowledge scores were most commonly measured patient-centered decision support tools tailored to support
immediately after the intervention was given or within 6 weeks. pregnant women. Furthermore, the studies in our review covered
Therefore, whether gained knowledge lasted over time is a wider range of topics during pregnancy, but coverage of the
unknown. One study [20] found no difference in knowledge most common topics regarding women’s health during
between women receiving genetic counseling about prenatal pregnancy was still lacking (eg, decision support tools for nausea
screening with and without a supplementary app. The fact that and vomiting in pregnancy).
both groups received a high-standard intervention such as
genetic counseling could possibly explain why there was no
What Makes a Good Decision Support Tool for
additional benefit of the app on knowledge scores. Taken Pregnant Women?
together, these results indicate that decision support during The most effective decision support tools for pregnant women
pregnancy, regardless of whether it is written or digital, may shared some common features. First, digital decision support
be a useful complement to standard antenatal care when tools seem more convenient if evidenced-based and if relevant
specialized counseling is less available. It is still important to information from different sources can be assembled in one
bear in mind that women receiving a consultation in advance app. This will avoid multiple or conflicting information sources,
may have been influenced to read more, which may have which has previously been an important concern among
affected the results. pregnancy women [50].
The studies included in this review show the potential of a Second, digital tools that enable pregnant women to share
patient-centered decision support tool to promote recordings with their health care providers and get real-time
communication between health care providers and women. feedback seem to be the most useful [18,29,32]. Such tools
Women who frequently used digital support tools were more enable individually tailored information and improve
likely to bring their recordings to their health care provider. communication during pregnancy. This is in line with previous
They were also more satisfied with the care they received and findings on weight gain in pregnancy showing that specific and
discussed their concerns with the health care provider to a tailored information is more effective than general information
greater extent than their counterparts did [27,29,31,38,40]. This [34].
indicates that women are more likely to discuss their problems
Lastly, digital decision support tools were more convenient for
with their health care providers when they are knowledgeable
recording symptoms than spiral notebooks. Women using digital
about the topic [44-46]. It should be noted that many of the
support tools recorded their symptoms more frequently [38].
studies included samples of women of higher sociodemographic
An earlier study [51] comparing the use of digital tools and
status than that of the general population of pregnant women.
spiral notebooks in general also reported that digital tools are
This may have caused a selection bias of potentially more
potentially more accurate. This indicates that future development
resourceful or motivated women, limiting the generalizability
of decision support tools should focus and invest in digital tools.
of the findings to all pregnant women.
A Supplement, Not a Replacement
Interpretation in Light of Other Evidence
Even with increased technology, there is still a gap in the
The use of decision support tools, in general, improves patient
development of patient-centered decision support tools for
knowledge, make them better informed, and makes their choices
pregnancy-related conditions. Given that women have high
and options clearer [47,48]. This review shows that this also
information needs and the potential that decision support tools
applies to pregnant women. Mobile apps and decision support
have in empowering them, we expect this can be a valuable
tools are increasingly used for self-management in many
supplement for both women and their health care providers
different chronic diseases that women of reproductive age have,
during prenatal care. Given that women were more satisfied
such as migraine and diabetes, but high-quality decision support
with and were more likely to discuss their health problems with
tools developed specifically for pregnancy are, to a large degree,
their care providers [30,31,38,40], it seems plausible that

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patient-centered decision support tools may promote healthier to the studies may have been motivated to participate, which
pregnancies and reduce the burden on health care services, with can cause a selection bias and give more positive results than
little extra cost after development. Decision support tools do what would be achieved in the typical target population.
not replace health care providers but provide additional relevant
Studies including decision support tools used by health care
clinical information, supporting women to make better decisions
providers, decision support tools regarding childbirth, maternal
together with their health care providers.
and fetal health outcomes, and decision tools used in the
The sparseness of studies evaluating the effect of decision postpartum period were excluded. An expanded review
support tools, especially on clinical outcomes, stands in great including these outcomes and topics should be assessed in future
contrast to the number of apps targeting pregnant women. This studies and may provide greater insight into the field.
highlights the importance of developing and testing decision
support tools for pregnant women. Only tools that are of high
Conclusion
quality and that are efficient should be promoted. Despite the technological possibilities, the focus on patient
involvement, and documented information needs, few
Limitations heterogeneous studies have been performed on the effect of
This literature review has some limitations that should be taken decision support tools in pregnancy. These few studies, however,
into consideration when interpreting the results. First, there have demonstrated the potential benefit to knowledge,
were few patient-centered decision support tools within each perception, confidence in decision making, and communication
topic, and the diversity of outcome measures made it challenging between the women and their health care providers. More
to draw overall conclusions. Second, the individual studies decision support tools should be developed and tailored to meet
overrepresented women with higher sociodemographic status, the needs of pregnant patients. The effect of such tools on
and the majority of pregnant women included in the studies clinical outcomes should be tested before recommending them
were of a white ethnic background. Third, a number of studies or implementing them as a supplement in routine maternity
had a low number of participants, and the women who consented care.
Acknowledgments
The authors would like to thank the librarians at the University of Oslo Science Library for their feedback on the literature search
and for providing the studies that were not available online. The authors also wish to thank the University of Oslo Medical Library
for their valuable course on the use of the review management tool Rayyan.
The study was funded by Foundation Dam through the Norwegian Women’s Public Health Association. HN is funded by the
European Research Council Starting Grant DrugsInPregnancy (grant number 639377).
Authors' Contributions
EN, MT, and HN designed the study. EN and MT performed the systematic search and conducted the main analysis. EN drafted
the first version of the manuscript. EN, MT, and HN contributed to the interpretation of results and critical appraisal of the
manuscript. All authors approved the final manuscript.
Conflicts of Interest
None declared.
Multimedia Appendix 1
Search strategy.
[DOCX File , 41 KB-Multimedia Appendix 1]
Extraction sheet.
The characteristics of studies included in this review.
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Edited by G Eysenbach; submitted 17.04.20; peer-reviewed by M Ceulemans, W Gyselaers; comments to author 12.06.20; revised
version received 25.06.20; accepted 25.06.20; published 14.09.20
Please cite as:
Ngo E, Truong MBT, Nordeng H
Use of Decision Support Tools to Empower Pregnant Women: Systematic Review
J Med Internet Res 2020;22(9):e19436
URL: http://www.jmir.org/2020/9/e19436/
doi: 10.2196/19436
PMID: 32924961
©Elin Ngo, Maria Bich-Thuy Truong, Hedvig Nordeng. Originally published in the Journal of Medical Internet Research
(http://www.jmir.org), 14.09.2020. This is an open-access article distributed under the terms of the Creative Commons Attribution
License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete
bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information
must be included.

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JOURNAL OF MEDICAL INTERNET RESEARCH Ngo et al

Use of Decision Support Tools to Empower Pregnant Women:

(J Med Internet Res 2020;22(9):e19436) doi: 10.2196/19436

that are best for themselves and improve communication with

Methods Study Selection and Data Extraction

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search (January 18, 2019) from the 5 online databases, with

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Pregnant women at ≤26 gestational weeks were included in

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Gestational Diabetes and Weight Gain Depression

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